1st June 2020 at 10:23 am #792RosMember
Recovery plans are underway across the country, impacting on service delivery and teaching in dental radiology.
Some initial questions which have been raised in email:
1. The use of intraoral imaging
2. PPE requirements
3. Management of waiting lists for routine patients referred before the pandemic.
Please use this thread to discuss how your unit is managing these issues, or any others you are experiencing, so we can learn from each other.
Thanks, Ros1st June 2020 at 11:10 am #793DAndrew1Member
Intra-orals & PPE: part of the same thing, so dealt with together. Our Radiographers are quite happy doing intra-orals with the following: plastic pinny, standard surgical mask, gloves plus a visor. As far as supply of PPE goes, we are at a stage where demand is so low that current PPE stocks are fine. We have an idea of what daily throughput might be, based on a few basic calculations regarding activity rate, waiting room capacity etc. Once mainstream NHS dentistry picks up things may be different, but its what we do with students that is taxing minds here. There is talk of a 3 session 12 hr day.
Waiting lists: we have about 100 on a waiting list. Majority are for US, with cone beam and sialograms making up the rest. We have started doing CBCT scans whilst we are quiet in order to get through them, and most are for elective surgery on young fit patients. Not many of the US patients want to come in, perhaps because they are older. Those who decline are notified to their referrer to ask whether the test is still needed.
GDPs will have a back-log of OPT requests that will come through quite quickly once they open their doors. We have stopped offering a walk-in service for this and all examinations can now only be done on a booked basis, taking into account our throughput calculations.
David, Sheffield2nd June 2020 at 10:50 am #794KirstynDMember
Thanks Ros. Situation in Glasgow is similar to what David has described.
Intra-orals: We were initially only undertaking DPTs and Occlusals at the start of lockdown but as the Scottish CDO has been changing what treatment can be carried out we have been adapting our protocols and are roughly back to normal in terms of undertaking periapicals.
PPE: We are using the same PPE as Sheffield. The only difference would be if I am planning on doing H&N ultrasound guided biopsies. The H&N radiologists in Glasgow have all been fit tested for FFPE 3 masks, as per BSHNI guidance and my management have said it would be up to me to determine if I needed fit tested. I don’t routinely biopsy so fit testing hasn’t been organised at the moment.
Waiting lists: Where do I start?! Due to equipment failures prior to COVID19 and staffing changes, we have significant waiting lists for CBCT, Ultrasound and Sialography. Ultrasound (roughly 200 patients) have been re-vetted by me so that I can get the more “urgent” cases in ASAP – all suspected cancers have been sent to another site so hopefully there are none of those on my list. I should hopefully be restarting ultrasound in the next few weeks as H&N at other sites have already restarted. I won’t be able to do sialography until our radiographer staffing levels have improved.
CBCT is a different story – roughly 400 patients waiting! Our waiting list is getting filtered by consultant and sent back to referrer to reprioritise these cases as we are unsure when these patients will be getting treated and if treatment is still required. A lot of the cases we would have normally said should have been done on a soon basis (cysts/other pathology) have been refusing treatment under LA only which may delay their surgery due to lack of Sedation/GA capacity and we don’t want to repeat scans unnecessarily. We are hopefully restarting CBCT in the next few weeks but again, this will be radiographer staffing level dependent. Similarly to Sheffield, there has been talk of a 3 session 12 hour day and potential weekend working to increase the volume of patients coming through the hospital but there is not enough capacity in radiology to support this plan.
I think apart from our huge waiting lists, our concern as a department is the training of the students when they come back. All our first semester lectures are being done virtually but planning how to deliver the practical skills is causing problems without us resorting to a phantom. The Glasgow department has very limited space for maintaining social distancing and as already mentioned we have reduced staffing levels and not all staff are trained to supervise students. A high percentage of our radiographers are rotational with other sites and haven’t been at the dental hospital for nearly 3 months, which will also potentially be a problem. Any ideas would be appreciated!
Hope everyone is staying safe and hopefully we can see each other soon.
Kirstyn, Glasgow2nd June 2020 at 1:36 pm #795Nicholas DrageMember
Thanks for the posts so far – very useful.
We are undertaking intraorals and panoramic radiography with disposable apron, surgical mask, visor and gloves. For covid suspected patients we currently use FFP3 masks but that is likely to change following guidance that intraorals are not considered to be AGPs but are awaiting confirmation on this change to our practice.
We are not undertaking any routine US or CBCT scans. I was hoping to get through the CBCTs while it was quiet but I have not been given the go ahead yet on this. Hopefully as Wales has had some lockdown easing at the start of this week this might change. I have concerns that if we did the scan the patient might not be seen by the clinician for many months reducing the validity of the scan and possibly leading to a rescan (Concern raised by Kirsten). I will probably contact the clinicians first to check the scan is still required and that they are happy for us to proceed with the scan.
No talk of a 3 session 12 hour day yet, but we are currently running a 7 day emergency rota within the dental hospital. Not sure how much longer that will continue for though.
We can deliver lectures and seminars remotely without issue using Zoom. The radiography teaching is much more difficult to organise. Manikin teaching is possible but of limited benefit if the students have already been taking radiographs on patients earlier on in the course. Social distancing is very difficult in the department too and we could probably only manage 2 students at a time as opposed to 4-5, which we accommodate at the moment. I am looking at the virtually radiography programme by qbion, designed by Jan Ahlqvist (who some of you will know/recognise).
It looks a useful teaching aid but is not a replacement for practical radiography experience. I’ll have to think more on this one.
Keep safe and well.
Nick, Cardiff4th June 2020 at 3:38 pm #firstname.lastname@example.orgMember
Greetings from Bristol.
We have been using the same PPE as everyone else for radiography – plastic apron, gloves, surgical mask and visor, including PAs DPTs and CBCT. Most radiologists have been using FFP3 masks for their US lists with biopsies. They have been keeping on top of the 50 or so urgent patients each week. There is a wait list for the routines which gets reviewed regularly with some being brought forward. We are doing OK with CBCTs. We’ve been doing urgents all the way through. For the others we contacted all our referrers asking them to consider whether CBCT was still needed and how urgently or whether we should be waiting until it was clearer when they would be able to treat.
Bristol has similar problems concerning the practical radiography teaching this autumn. Our current third years will have missed 15 weeks of their practical training if they come back for October 5th which is the soonest date we’ve been given by the University. We gave them a program of e-learning this summer for the theory of the techniques, positioning faults, and caries/ apical change etc., but have no way of compensating for the missed practical sessions. We will have at best 8 weeks in the autumn to try to catch up, but like Cardiff will not be able to have more than a couple in the department at once instead of 4-5. There is no way we will be able to do the usual intra-oral and DPT competency tests after that limited amount of experience. (We can’t move them on into later terms because 2020/2021 we have a curriculum change which involves radiography teaching for the 2nd and 3rd years at the same time with the same resources i.e. the next two years will only get half the usual teaching as well.)
Haven’t heard anything about extended days and Saturdays yet. Seems like a sensible idea, though staffing is always a problem.
We’re very interested to know what you think of the qbion virtual radiography program Nick. Had a quick look but can’t see it really addressing our problem.
Jos, Bristol5th June 2020 at 10:38 am #800Nicholas DrageMember
Hi Jos and everyone
We had a demonstration of the system. It is good for what it is. It allows you to position the image receptor and spacer cone virtually and shows you what the resultant images look this. Similarly it allows you to move the patient about when positioning for panoramics and shows you what the images would look like. Due to the processing required it has to be installed physically on a computer so could not be accessed off site by the students. It is designed to run alongside a practical radiography course rather than as a substitute.8th June 2020 at 5:11 pm #801DAndrew1Member
Update re: teaching BDS students
Uni. doesn’t want students back until September 2020. We have plans to get the year closest to graduation back 1st and do some online prep and then clinical skills work prior to clinical teaching. Latest document from Dental Schools Council makes for sobering reading about what is achieveable and what clinical experience we can give the students prior to graduation – it is likely to be very different from before. PPE is likely to be the sticking point given Matt Hancock’s missive that all NHS staff in English Hopsitals will need to wear a surgical mask.
All lecture teaching is to be done online, either recorded or interactive if you want the audience to be there during your talk.
2nd years are the most disadvantaged from a Radiology perspective as just as they were to start clinical work, inc. Radiography, the rug was pulled from under their feet. The throughput of patients through the X-ray dept is so slow currently that even if we did have students on site, there’d be nothing for them to do anyway, so the Qbion system may be useful from a training perspective, will have to look into it.
David17th June 2020 at 1:29 pm #803bmurrayMember
1. for HOT patients – we radiograph them in the treatment room so are using intra-orals where possible. We have reverted our dept back to cold and an OPT will be made HOT as when required but only been asked to do 1 OPT for a HOT patient since the start of the pandemic and numbers in the HOT stream were never big but are continually decreasing.Have used FFP3 for HOT patients as had agreement that our staff going into to radiograph them should be offered the same protection as those treating them. Was easier to do as they are going physically into a HOT zone.
2. 300 routine patients on waiting list – have asked clinicians to validate the list. From this week have been appointing patients up to 10/day. Will keep under review to see how patients flow fits in with other departments starting up. Extended days and weekend work are being considered. We have had staff volunteer for overtime but will also consider modifying work patterns and assess on an individual basis.
3. Reduced staffing at minute helping with social distancing and as we have no students hoping that patient flow through will be good. Encouraging OPTs where possible to help with this but will take intra-orals if needed but am not concerned about taking intra-orals with standard PPE. Standard PPE as others for cold patients.
4. Staffing will may be an issue when students come back and social distancing will be an issue. May look to provide phantom teaching off dept if possible. Think we have to be realistic and accept that students won’t get the practical experience they have had previously and that will be in line with all aspects of training. Will look at other resources (thanks for the tip Nick) and the emphasis in terms of radiology/radiography will be different. Lectures being delivered remotely.
5. US running – currently using standard PPE for cores/FNAs but this may be changed as we start seeing more routine patient with pre-procedure swabs being considered and FFP3 on an individual’s vulnerability.
6. Have recommenced sialograms, interventions and macrodacros.
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